Public meeting - 01/12/05

Western Isles NHS Reform
Presentation by Western Isles NHS Board
Location: Caberfeidh Hotel, Stornoway
Date: 1 December 2005, 18:00 hours
Chair: Mr Dick Manson, Chief Executive WIHB
Attendance: 150

Notes taken by myself in a private capacity

Presentation is fronted by:
Dick Manson, Chief Executive
Dr John Smith, medical director
Prof Andrew Sim, professor of Rural and Remote Medicine UHI
Cathy Carnell, general manager hospital services
Michael Cook
director of nursing
(apologies: could not take down everybody's details)

Dick Manson started by giving a 30 minutes' presentation (promised as 15 mins), outlining first of all the challenges facing the NHS in the Western Isles
- ageing population
- an increase in chronic disease
- an increase in emergency admissions, a quarter of which are aged 65 or over
- EU working time directive
- shortage of clinical staff (generally in Scotland)
- advances in medical science, difficult to keep up with
- expectations from the public

The NHS is there to meet health needs.

The Western Isles has a unique demographic profile.
Total population: 26,500
The life expectancy for men is the 3rd worst in Scotland, 72 years of age.
The life expectancy for women is the 3rd best in Scotland, 80 years of age.
Avoidable illness is too prevalent
Population in the Western Isles consists of a high percentage of elderly people, higher than anywhere else. 1 out of 5 people is aged 65 or over
The number of young people is decreasing, although their rate of academic achievement is better than elsewhere in Scotland
Birth rates are falling; expecting to go down from 220 last year to 150 in 2010
Crimerate is lower than average
Incomes are 14% lower than average for Scotland
House prices are lower
Unemployment rates are higher
The rates of alcohol-related admissions is much higher
There are higher numbers of people suffering from heart conditions and depression

The NHS is very well used.
Every day, the hospitals have 150 inpatients
20 attend A&E
18 patients are admitted or discharged
320 people see their GP
1380 prescriptions a day are dispensed

Doctors:
16 consultants
11 doctors-in-training
35 general practitioners
3 GP registrars [in training]
This represents an unrivalled clinical resource
There are 229 hospital beds (spread out over the 3 sites Stornoway, Benbecula and Barra), 30% of which are unused

Service redesign
This has been imposed by government, and should be from bottom up
More than 100 people have been involved, NHS staff as well as patients
It should provide a sustainable model for the next 10 years

There were a number of redesign groups

1 Primary Care Out-of-hours
There will be a move from GP's on-call to emergency care teams. These consist of nurses, paramedics and a GP

2 Surgery
Four surgeons are to provide core-services for all types of surgery, including orthopaedics, general surgery, obstetrics and gynaecology

3 General medicine
Will be moving to a multidisciplinary approach (doctors, nurses, allied health professions [physiotherapists, pharmacy &c]. There will be 4 consultant physicians, which should be enough to provide a 24/7 service

4 Maternity (Cathy Gillies)
This service is to be retained locally. It is to be midwife-led, with support by a consultant obstetrician and a surgeon. There will be a rota for a safe service. Training of midwives has already started, with telemedicine (for backup) and a consultant paediatrician

5 Paediatrics (Chris Langley)
Paediatric care to be provided by GPs, consultant physicians and a consultant paediatrics for support. Training to start next week

6 Public health (Lucy MacLeod)
Is to tighten its links with the local authority and other agency. Training has commenced for national accreditation

7 Psychiatry (Dr Caulcott)
Service to be retained here. The skills of existing professional is to be enhanced.
Care will be CPN [community psychiatric nurse] led; with GPs in the Uists

8 Medical trainees (Dr Dickie)
Western Isles Hospital will continue to be a training centre, and the aim is to maintain skills in this hospital’s environment.

9 Renal services (Phil Tilley)
A renal dialysis centre is to be established at WIH; a lead-nurse has been appointed

10 Radiology (Malcolm McNinch)
A radiologist is available 3 days out of every 7
The service will be radiographer (sic) led, i.e. by the people that take the images. They will be sent by telemedicine (electronically) to a consultant radiologist at a mainland centre. Training has commenced

Core services
General medicine
Surgery & orthopaedics
Anaesthetics
Maternity & paediatrics

There will be 8 permanent consultants, and 9 on long-term locum contracts. The aim is to minimise locums, because they are unfamiliar with local working practices.
Long term locums are paid a normal rate; short-term locums are paid an hourly rate, determined by an agency which can charge up to £70 an hour. If someone is working or on-call 24/7, then this works out as £11,800 per week, as reported in the media.  

Visiting consultants in other specialities (ophthalmology, rheumatology &c) will offer support.

Key Themes
Break down barriers between primary and secondary care
Establish a multi-disciplinary approach
Develop [new] roles for nurses, allied health professionals (AHP) and doctors
Education and training
Remote and rural healthcare: models were developed for the big cities, not for an area like the Western Isles or generally the north of Scotland

Implementation groups will consist of clinical staff, nurses, AHP, support staff and members of the public. A timetable was giving for the implementation

Redesign groups: for Uist & Barra hospital (led by Mr Manson) to optimise utilisation of resources at the Benbecula hospital

The aim is to establish a safe, sustainable service, backed by (mainland) centres of expertise, leading the way in remote / rural healthcare. The care will be as local as possible, and as specialised as necessary.

This was the end of Mr Manson's presentation. The remainder of the meeting, between 6.40 and 8.00 pm, was taken up with a question and answer session. Some of the answers to questions have been worked into the words of Mr Manson, for the sake of clarity.  

Cllr for Bayble (Point) asked questions about the redesign of the structure of the Health Board and the provision of psychiatric care, now that the two psychiatrists are retiring

Mr Cook replied that there would be wider training for staff. A meeting with CPNs and medical staff for short term solutions would be sought. Dr Caulcott is going on holidays for 6 months from December 5th, for which a locum would be required. An advertisement for a permanent position would be placed.

Mr Manson replied that the Health Board review would be carried out in the longer term, but current focus would be on frontline services, in cooperation with CnES.

The Cllr remarked that provisions should have been made for the vacancy, which should have been advertised a long time ago. The review appears to be a top-down exercise.

Mr Manson replied that the overheads for WIHB are the lowest in the 6 Health Boards in the north of Scotland (Orkney, Shetland, Highland, Grampian, Tayside and W. Isles).

One other councillor asked about travel expenses
Mr Manson replied that the vast majority of these are on actual health board business, to enhance services.

A service user for psychiatric care expressed concern about the continuity of care in community, and in-patient beds. The waiting time for specialist care was too long. Locums don't cut it, you need regular staff. Oh, Mr Manson, your bodylanguage is wrong. You're condescending (!)

Mr Manson apologised for the last impression.
Dr Michie noted that a number of beds might be retained for emergencies, but this depended on the outcome of the service review.
The user remarked that if care is dispersed to GPs, expertise might be lost
Dr Michie conceded that resources are problematic

One member of the audience read out a statement to Mr Manson, on behalf of a large majority of the nurses.

The nurses are fed up, demoralised and intimidated. A rule of Stalinism is alleged, a reign of fear. Complaints are not made because of fear. Proposed ward closures bring shame on the health board. It is a corrupt regime, devoid of any decency. If grievances are uttered, disciplinary action is taken against the relevant members of staff. Changes are always top down. The working groups consist of management level staff, who impose their own ideas after slapping down workers’ ideas.

Dr John Smith replied to this.
Changes are being implemented from the roots upwards, in order that it’s the workers’ project. There is a movement of care to the primary sector. WIHB is engaging with staff to implement changes.

Professor Sim expanded on some of the themes, touched upon by Mr Manson.

Care is to be offered primarily by trained staff, and skills are to be taken over by other health professionals, which is UK policy. The junior doctor, apart from looking after patients on a day-to-day basis, will focus on their training.

There is a change in surgical practice. The hospital stay after an operation is much shorter. After (e.g.) a gall-bladder operation, a patient can normally expect to go home after 2 days, was 2 weeks. Because of this, the surgical wards will change into one 7-day ward (including paediatrics) and one 5-day (a week) ward.

Medicine will focus on care at home rather than in the hospital because many of the beds on the medical wards lie unused. These unused beds are to be closed.

Obstetrics and orthopaedics: general surgeons will be trained to do work in these fields.

The aim is to provide a safe service, performed by professionals who are properly trained for everything they’re required to do.  Transfers to mainland hospitals are to be reduced to the absolute minimum.

A renal and a stroke unit are to be established, using the beds no longer in use on the medical wards. The lead nurse for renal care has been appointed, but will not be in post until February 2006.

There will be no redundancies, but temporary contracts will NOT be extended.
Focus will be on staff retraining and to enrich nursing skill mix. Nurses will be redeployed, to community care. Staff have had a similar presentation in the weeks leading up to today.

Uist & Barra Hospital (Balivanich, Benbecula) is only 4 years old, and has state-of-the-art equipment. Unfortunately, it does not have the facilities to provide the necessary aftercare.

Angus MacNeil, Western Isles MP expressed his concerns about staff morale and wanted an explanation about soaring locum costs.
It was explained that only 4 locums in the last year had been paid the massive £11,800 a week rate. When you’re on-call, you are not actually working – you’re available for work.